HSJ reports that the financial support given to trusts has reached record levels. Some of the money is easing them over the final hurdle to foundation status, but a significant proportion is being employed to support failed organisations while alternative solutions are devised. Over the next two years, we are likely to see trusts slide from the former category into the latter as they fail to live up to Monitor’s demanding expectations. This will increase the pressure for reconfiguration, pressure which in some cases has been building for a decade or more.

So what will be different this time? Will we see a cash-driven rationalisation, a realistic right-sizing of the acute sector with patient safety to the fore, or will caution reign?

How long will it be before MPs and other campaigners label the clinical commissioning group leads signing off the reconfigurations as “faceless bureaucrats”? And once battle is joined, who will the public trust, and who will they blame?

Readers' comments
(9)

Anonymous | 17-May-2012 10:33 am

Whatever your political persuasion, it is very clear to see that there is an urgent need for hospital capacity rationalisation and MPs need to start helping a more constructive debate at a local level.

Paul Burstow has a massive conflict of interest and should bow out of the matter affecting his local hospital.

The emotion surrounding closure of A & E is purely psychological because what takes place behind the doors of A & Es is changing any way. People with emergency stroke, cardiac, vascular and increasingly major trauma are taken to specialist hospitals, bypassing their local hospital when appropriate.

The population readily accept that it is better for them to be treated at a hospital that is more experienced and specialises on particular major conditions.

Psychologically, it would be better to keep A&Es open to deal with what they can and allow the trend to specialisation to continue.

More collaboration between neighbouring hospitals is a key step to dealing with this.

"Whatever your political persuasion, it is very clear to see that there is an urgent need for hospital capacity rationalisation and MPs need to start helping a more constructive debate at a local level."

The electorate will punish almost any MP not backing a 'knee jerk' campaign to keep a particular local service open in their constituency. We get the MPs we vote for.

Maybe it's time for MPs to demonstrate some leadership rather than cowardly recourse to "Save our Hospital" sloganising. All across the South East there are health facilities which add cost to the system and should have been rationalised years ago. This results in a dilution of resource which is therefore a dilution of the quality of care. I would rather travel twice as far for a clinician to give me th best care, because of the volumes (s)he is used to delivering, rather than pop round the corner to an A&E which has no senior staff after 5pm, sees a cardiologist when there's an R in the month and the staff are stretched beyond fatigue by stretched shifts and sheer slog. Time for MPs to speak for the long term benefits of the system change not for their own short term personal profile. To single out Paul Burstow would be invidious- there are so many like him.

All the people advocating bravery here do so anonymously and make a whole series of statements for which they present no evidence and assertions based on personal preference - pretty typical of the cavalier approach NHS management takes to evidence.

It's the decision to train fewer doctors and pay them more than anyone else in Europe that is the reason for most of these changes. The benefits of quality and specialisation can be achieved with smaller numbers seen by most current DGHs for most medical conditions (STEMI and stroke excepted) and this is the case in Europe.

Once it would be the fault of elected politicians if faceless 'health chiefs' got their way and shut a hospital. Very soon it will be possible to blame either GPs, or - best of all - the patients themselves.

"But you didn't *choose* your local hospital", they'll be told. "If you valued it so much, why didn't you get treated there more often?"

Of course, everyone who wanted the hospital to stay open will assume that they were among the loyal group who kept on choosing local, and that it must be the fault of their particular scapegoat group that the place shut.

Anon 8.11 amYour comments about the bravery or otherwise might have slightly more substance if you too had not posted anonymously !

There's very good HR (concern over jobs) reasons why people post anonymously at this point in time. It's nothing to do with an approach to evidence. And byy my reckoning, your assertions about medical staffing appear pretty thin on evidence too.

So is it always the case that bigger is better and sharing clinicians is always inefficient? I detect some arrogance in the comments. Are we confident that the implications of centralisation for the emergency and support services are diligently followed through. There are more than hints of ideology in the thinking. Is it OK to travel 20 miles to get a broken leg properly fixed?

When I worked in specialised commissioning, we had a large number of medically led evidence based debates with external peer reviews regarding the whole quality versus access debate. There are clearly a number of services where it isn't the case that the more you do, the better you are, because activity's inversely proportional to outcome - there's a greater correlation between outcome and say infection control or ratios of nurses to patients in high dependency units. There are other procedures where there is a correlation - you become safer the more practised you are. But what was interesting was how this changed over the 10 years I worked. Something once seen as routine became far more complex (e.g. upper GI surgery) because new techniques like laparoscopy meant you could do more things. And in turn, take on more complex patients. So the detail on what constitutes a good service for X isn't static. It's hard to work out all the factors that make provision A "better" than provision B, which is why you need to involve all the professions and a wide evidence base.

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